Organ transplantation has saved countless lives, increasing the demand for unpaired solid organs. As a result, the protocols for organ procurement continue to change to include more patients as “dead.” The Dead Donor Rule is the overlying premise of organ procurement: donors must be dead prior to organ retrieval, they cannot be made dead to obtain organs and obtaining organs cannot result in their death. The protocols are complicated and difficult to understand with the intent of convincing us the patient is “dead;” therefore, organ retrieval will not be the proximal cause of the patient’s death. Changing definitions and terms also helps to obfuscate the definition of death. The current procurement protocol that is creating controversy is called NRP-cDCD (normothermic regional perfusion with controlled donation after circulatory death). A little history and background first.

 

People think about unpaired solid organ donation occurring after the patient has been declared dead, usually by Death by Neurological Criteria (brain death). As most neurologically devastated patients will not progress to brain death, DCD (donation after circulatory death) protocols were developed: the family requests withdrawal of life-sustaining therapy (LST); the family pursues organ donation; the patient is taken to the operating room and withdrawal of LST occurs; within one hour the patient comes to cardiac standstill; the team waits five minutes to declare the patient dead; and then organ procurement occurs. There are technical issues with DCD, including the patient may not come to cardiac standstill within an hour, and the organs have warm ischemia time, thus making some of the organs unusable. There are also ethical issues with DCD including:

 

1. Concern that removal of the organs causes the patient’s death rather than withdrawal of LST; and
2. The patient may not meet criteria during the time period and cannot donate, thus creating distress for the family who expected donation.

 

A variety of protocols have now been developed to improve the odds of organ procurement and to decrease warm ischemia time. NRP-cDCD is such a protocol. The patient undergoes withdraw of LST and comes to cardiac/circulatory standstill. The transplant surgeons then attach the patient to an external circulatory circuit (ECMO or cardiopulmonary bypass) deliberately excluding the brain (to ensure brain death occurs). The heart is restarted as Normothermic Regional Perfusion (NRP) occurs, and after a period of organ reperfusion, the organs are procured. The concern is the patient was declared “dead” by cardiac/circulatory criteria (heart not beating), and those conditions are reversed in this protocol (the heart is restarted once the cannulas are in place). The protocol also causes brain death by excluding blood flow to the brain. Both of these issues violate the Dead Donor Rule. (Watch this video.)

 

The debate about all forms of DCD organ procurement is intense, resulting in multiple justifications: the patient is going to die anyway; the patient and family want to donate, therefore we should do everything to make that possible; brain death is arbitrary; the dead donor rule is also arbitrary and should be eliminated; and the presupposition that all organ transplantation is “good” so whatever is done to obtain these organs is “good” permeates the world of solid organ transplantation. Around the world organ donation is tied to euthanasia, including Canada. We are well on our way there.

 

 

---

References

 

Croome KP, Taner CB. The Changing Landscapes in DCD Liver Transplantation. Curr Transplant Rep. 2020;7(3):194-204. doi:10.1007/s40472-020-00283-1

 

DeCamp M, Snyder Sulmasy L, Fins JJ. POINT: Does Normothermic Regional Perfusion Violate the Ethical Principles Underlying Organ Procurement? Yes. Chest. 2022;162(2):288-290. doi:10.1016/j.chest.2022.03.012

 

Dhanani S, Hornby L, van Beinum A, et al. Resumption of Cardiac Activity after Withdrawal of Life-Sustaining Measures. N Engl J Med. 2021;384(4):345-352. doi:10.1056/NEJMoa2022713

 

Kalisvaart M, Croome KP, Hernandez-Alejandro R, et al. Donor Warm Ischemia Time in DCD Liver Transplantation-Working Group Report From the ILTS DCD, Liver Preservation, and Machine Perfusion Consensus Conference. Transplantation. 2021;105(6):1156-1164. doi:10.1097/TP.0000000000003819

 

Mulder J. Facilitating the wishes of patients who choose both MAiD and organ donation. CMAJ. 2019;191(22):E595-E596. doi:10.1503/cmaj.190352